What is the management for a patient with fever, pharyngitis, headache, abdominal pain, nausea, vomiting, and chills?

Management of a 15-Year-Old with Generalized Body Aches, Sore Throat, Headache, Abdominal Pain, Nausea, Vomiting, and Chills

This adolescent requires immediate clinical evaluation to exclude Group A Streptococcal (GAS) pharyngitis and to assess for serious bacterial infections including meningitis, while recognizing that viral illness is most likely.

Immediate Clinical Assessment

Critical Red Flags to Exclude First

• Assess for meningitis/meningococcal sepsis: Document presence or absence of altered mental status, neck stiffness, fever, rash (any description), seizures, and signs of shock (hypotension, poor capillary refill) 1
• Urgent hospital referral is mandatory if meningitis is suspected, as patients can deteriorate rapidly 1
• Do not rely on Kernig's or Brudzinski's signs for diagnosis, as they have poor sensitivity 1

Structured Clinical Evaluation

Obtain the Centor criteria to stratify risk for GAS pharyngitis 1, 2:

• History of fever
• Tonsillar exudates
• Absence of cough
• Tender anterior cervical lymphadenopathy

Document additional symptoms that suggest viral etiology 1:

• Presence of cough, conjunctivitis, hoarseness, coryza, or diarrhea strongly suggests viral rather than streptococcal infection 1
• Headache, nausea, vomiting, and abdominal pain can occur with both GAS pharyngitis and viral syndromes 1

Diagnostic Strategy Based on Centor Score

If 0-1 Centor Criteria Present

• Do not test or treat - viral illness is most likely 2
• Provide supportive care only 2

If 2 Centor Criteria Present

• Perform rapid antigen detection test (RADT) for GAS 2
• Treat only if RADT is positive 2
• Throat culture is not recommended for routine evaluation in adults/adolescents 2

If 3-4 Centor Criteria Present

Two acceptable approaches 2:

1. Perform RADT and treat if positive, OR
2. Treat empirically without testing (acceptable for 4 criteria)

Antibiotic Therapy (Only if GAS Confirmed or Highly Likely)

Penicillin is the preferred antibiotic for confirmed GAS pharyngitis 2

• Use erythromycin in penicillin-allergic patients 2
• Narrow-spectrum antibiotics are appropriate to minimize unnecessary antibiotic use 3

Supportive Care for All Patients

Provide symptomatic treatment regardless of etiology 2:

• Analgesics for pain relief
• Antipyretics for fever
• Adequate hydration
• Rest

Consider Alternative Diagnoses

COVID-19 Evaluation

In settings with COVID-19 prevalence, consider testing if the patient has 1:

• Fever, chills, muscle pain, headache, sore throat
• New loss of taste or smell
• GI symptoms (nausea, vomiting, abdominal pain) may precede respiratory symptoms by several days 1

Acute Viral Syndrome

This presentation is consistent with acute viral syndrome 4:

• Classic triad: acute onset fever, systemic symptoms (fatigue, body aches, chills), and absence of severe respiratory symptoms 4
• Supportive care with rest, hydration, and antipyretics is appropriate 4

Monitoring and Follow-Up

Instruct the patient/family to return immediately if 4:

• High-grade fever recurs or persists
• Respiratory symptoms develop or worsen
• Altered mental status occurs
• Signs of dehydration develop
• Symptoms fail to improve within 3-5 days

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically for patients with 0-1 Centor criteria, as this promotes unnecessary antibiotic use 2
• Do not dismiss the possibility of serious bacterial infection (meningitis, sepsis) based solely on the presence of common viral symptoms 1
• Do not assume viral pharyngitis in adolescents with 3-4 Centor criteria without testing or treating for GAS, as this age group has high rates of streptococcal infection 1
• Do not overlook COVID-19 in the differential diagnosis, especially when GI symptoms precede respiratory symptoms 1